Social and ethical implications of psychiatric classification for low- and middle-income countries

With the publication of the Diagnostic and Statistical Manual, 5th edition, and the ongoing revision of the International Classification of Diseases, currently 10th edition, it is timely to consider the wider societal implications of evolving psychiatric classification, especially within low- and middle-income countries (LMICs).  The author reviewed developments in psychiatric classification, especially the move from categorical to dimensional approaches based on biobehavioural phenotypes. While research supports this move, there are several important associated ethical challenges. Dimensional classification runs the risk of ‘medicalising’ a range of normality; the broadening of some definitions and the introduction of new disorders means more people are likely to attract psychiatric diagnoses. Many LMICs do not have the political, social, legal and economic systems to protect individuals in society from the excesses of medicalisation, thus potentially rendering more citizens vulnerable to forms of stigma, exploitation and abuse, conducted in the name of medicine and psychiatry. Excessive medicalisation within such contexts is also likely to worsen existing disparities in healthcare and widen the treatment gap, as inappropriate diagnosis and treatment of mildly ill or essentially normal people has an impact on health budgets and resources, leading to relative neglect of those with genuine, severe psychiatric disorders.  In an era of evolving psychiatric classification, those concerned for, and involved in, global mental health should be critically self-reflective of all aspects of the modern psychiatric paradigm, especially changes in classification systems, and should alert the global profession to the sociopolitical, economic and cultural implications of changing nosology for LMIC regions of the world

Mental health services funding and development in KwaZulu-Natal: A tale of inequity and neglect

Background. Globally, a significant ‘mental health gap’ exists between the major burden of mental and substance use disorders and the provision of psychiatric and mental health services. As a signatory to the UN Convention on the Rights of Persons with Disabilities, South Africa has committed itself to transformation aimed at ending the inequities that characterise mental health service provision and ‘closing the gap’. Methodology. Budget allocations over a 5-year period to 6 psychiatric and 7 general hospitals in KwaZulu-Natal (KZN) are compared and current numbers of psychiatric beds and psychiatric personnel in that province are contrasted with the numbers required to comply with national norms. Results. The mean increase in budget allocations to public psychiatric hospitals was 3.8% per annum, while that to general hospitals over the same period was 10.2% per annum. The median cumulative budget increase for psychiatric hospitals was significantly lower than that of general hospitals (Mann-Whitney U-test, p=0.001). No psychiatric hospitals received specific funding for tertiary services development. KZN has 25% of the acute psychiatric beds and 25% of the psychiatrists required to comply with national norms, with the most serious shortages experienced in northern KZN. There are 0.38 psychiatrists per 100 000 population in KZN. Conclusion. Inequitable funding, inadequate facilities and significant shortages of mental health professionals pervade the mental health and psychiatric services in KZN. There is little evidence of government abiding by its public commitments to redress the inequities that characterise mental health services

Green environment and incident depression in South Africa : a geospatial analysis and mental health implications in a resource-limited setting

Our results imply the importance of green environments for mental wellbeing in sub-Saharan African settings experiencing rapid urbanisation, economic and epidemiological transition, reaffirming the need to incorporate environmental services and benefits for sustainable socioeconomic development.Peer reviewe

Ancestral calling, traditional health practitioner training and mental illness:An ethnographic study from rural KwaZulu-Natal, South Africa

This qualitative ethnographic study complements an epidemiological study on first episode psychosis in Vulindlela, a rural area in KwaZulu-Natal, South Africa. It focuses on two themes that emerged from our data: (1) the calling of the ancestors to become a traditional health practitioner and (2) ukuthwasa, the training to become a traditional health practitioner. The purpose of this study is to describe the ancestral calling, and to explore whether ukuthwasa may help with the management of mental disturbances, including unusual perceptual experiences. We also provide a discussion of the changing sociopolitical context of healing in KwaZulu-Natal, as a background to our study. In-depth interviews were conducted with 20 (apprentice) traditional health practitioners, formal health practitioners, patients and relatives recruited through local traditional health practitioners and a health care clinic. Our results show that the ancestral calling might announce itself with symptoms of mental illness including unusual perceptual experiences, for which some participants consider ukuthwasa as the only effective cure. We found indications that in some individuals successful completion of ukuthwasa might promote recovery from their illness and lead to a profession in which the unusual perceptual experiences become a legitimate and positively valued aspect. We suggest that - in this particular community today, which has been subject to several sociopolitical changes - ukuthwasa may be a culturally sanctioned healing process which moderates experiences that a Western psychiatric system might characterize as psychotic symptoms, providing some individuals with a lucrative and respected role in society

Psychosocial and behavioural interventions towards HIV risk reduction for serodiscordant couples in Africa: A systematic review

Background: Sexual transmission of HIV frequently occurs in the context of a primary relationship between two partners; however, HIV prevention interventions generally focus on individuals at risk, rather than specifying couples as a unit of change and analysis, neglecting the crucial role that partners may play in sexual behaviour. This article reviews published scientific literature addressing couple-oriented HIV counselling and testing and other behavioural interventions using an online search for peer-reviewed papers. Methods: A systematic review was conducted to evaluate what has been published on psychosocial interventions in HIV serodiscordant couples in Africa. Electronic databases were searched from January 1990 to December 2015. Quality assessment of included studies was conducted using the Systematic Appraisal of Quality in Observational Research tool. Results: The electronic database searches initially retrieved 493 records; after cross-referencing, removing duplicates and applying strict inclusion and exclusion criteria, only eight papers were included in this review. All the studies under review showed that couples-focused counselling and educational programmes were associated with positive outcomes including reduced HIV transmission, reduced unprotected sex, increased rates of status disclosure and high levels of treatment adherence. Conclusions: The literature on interventions for HIV serodiscordant couples is sparse. However, most interventions indicate that couples-focused interventions are effective in HIV risk reduction. In spite of the limited available data and repeated recommendations by different health authorities, couple-centred approaches to HIV prevention have not been implemented on a large scale

Sexual trauma and post-traumatic stress among African female refugees and migrants in South Africa

Background: While there is considerable research in developed countries on the nature and extent of post-traumatic stress among refugees and migrants, few report on female Africans migrating within Africa. Aim: The aim of this study was to investigate the association between exposure to traumatic life events and post-traumatic stress disorder risk in refugees and migrants in Durban, South Africa, with specific focus on sexual trauma events among women. Methods: Interviews were conducted on 157 consenting non-South African adults using a sociodemographic questionnaire, Life Events Checklist (documenting traumatic events experienced) and the Harvard Trauma Questionnaire (measuring post-traumatic symptomatology). Associations between total number of traumatic events and post-traumatic stress were explored using adjusted regression models. Results: The results of one model indicated that greater numbers of traumatic life events experienced by women were associated with raised odds of post-traumatic stress disorder risk (β = 1.48; p < 0.001). Another model indicated that exposure to sexual trauma events were associated with greater odds of post-traumatic stress disorder risk (β = 4.09; p = 0.02). Conclusion: Our findings highlight the critical importance of mental health service for females with history of sexual traumatic events for this vulnerable population

Course of psychotic experiences and disorders among apprentice traditional health practitioners in rural South Africa:3-year follow-up study

Background: Culture is inevitably linked with the experience, interpretation and course of what modern biomedicine understands to be psychotic symptoms. However, data on psychoses in low- and middle-income countries are sparse. Our previous study showed that psychotic and mood-related experiences, symptoms and disorders are common among individuals who had received the ancestral calling to become a traditional health practitioner (THP) in rural KwaZulu-Natal, South Africa. Our related ethnographic study suggested that ukuthwasa (the training to become a THP) may positively moderate these calling-related symptoms. As far as we know, no research has been conducted into the course of psychiatric symptoms among apprentice THPs. Objective: We studied the course of psychotic experiences, symptoms and disorders among apprentice THPs. We also assessed their level of functioning and expanded our knowledge on ukuthwasa. Materials and methods: We performed a 3-year follow-up of a baseline sample of apprentice THPs (n = 48). Psychiatric assessments (CAPE, SCAN), assessment of functioning (WHODAS) and a semi-structured qualitative questionnaire were completed for 42 individuals. Results: At 3-year follow-up, psychotic experiences were associated with significantly less distress and there was a reduction in frequency of psychotic symptoms compared to baseline. The number of participants with psychotic disorders had decreased from 7 (17%) to 4 (10%). Six out of seven participants (86%) with a psychotic disorder at baseline no longer had a psychiatric diagnosis at follow-up. Although the mean level of disability among the (apprentice) THPs corresponded with the 78th percentile found in the general population, 37 participants (88%) reported no or mild disability. Forty-one participants (98%) reported that ukuthwasa had positively influenced their psychiatric symptoms. Conclusion: In rural KwaZulu-Natal, psychotic experiences, symptoms and disorders have a benign course in most individuals who are undergoing the process of becoming a THP. Ukuthwasa may be an effective, culturally sanctioned, healing intervention for some selected individuals, potentially because it reframes distressing experiences into positive and highly valued experiences, reduces stigma, and enhances social empowerment and identity construction. This implies that cultural and spiritual interventions can have a positive influence on the course of psychosis

Depression onset and its association with community HIV prevalence: A geospatial and panel analyses of nationally representative South African data, 2015–2017

The scaling up of antiretroviral therapy services over the past decades has led to a remarkable reduction in HIV infections and HIV-related deaths in South Africa (SA). While this is a step in the right direction, it brings a new public health challenge into focus, namely psychological challenges associated with such chronic and often stigmatising condition in SA, home to the largest HIV epidemic. Given the current lack of national-level evidence, we investigated the role of the HIV epidemic on depression onset in SA using nationally representative panel data from the South African National Income Dynamics Study (SA-NIDS). Our incident cohort consisted of 13,020 sampled adult participants who were depression-free in Wave 4 (baseline year of 2015). We then measured the risk of depression onset in Wave 5 (year 2017) based on the level of HIV prevalence in the community where study participants resided at baseline. A High-resolution map of HIV spatial heterogeneity (i.e., community HIV prevalence) was generated using ordinary kriging mapping methods from a separate nationally representative data source that corresponded to the investigation period. Geospatial analyses were conducted to identify the spatial structure of HIV and depression onset, and generalised estimating equations (GEE) regression models were fitted to determine the risk of depression onset over time based on community HIV prevalence. Our geospatial analyses indicated that HIV and depression onset prevalence spatially overlapped in the eastern part of the country, particularly in Gauteng, KwaZulu-Natal, Mpumalanga, and Free State province. The GEE regression analyses indicated that individual residency in a community with high HIV prevalence was significantly associated with a higher risk of depression than a low HIV prevalence community (adjusted odds ratio =1.45, 95% CI=1.12-1.48). For the first time, we identified a geospatial overlap between HIV and depression, with a greater risk of depression onset in high HIV prevalence communities, at a national scale in SA. There is a need for place-based policy interventions that prioritise the availability of and access to mental health services in high HIV prevalent SA communities, in an ageing HIV epidemic

Effect of aerobic exercise on amyloid accumulation in preclinical Alzheimer’s: A 1-year randomized controlled trial

Background Our goal was to investigate the role of physical exercise to protect brain health as we age, including the potential to mitigate Alzheimer’s-related pathology. We assessed the effect of 52 weeks of a supervised aerobic exercise program on amyloid accumulation, cognitive performance, and brain volume in cognitively normal older adults with elevated and sub-threshold levels of cerebral amyloid as measured by amyloid PET imaging. Methods and findings This 52-week randomized controlled trial compared the effects of 150 minutes per week of aerobic exercise vs. education control intervention. A total of 117 underactive older adults (mean age 72.9 [7.7]) without evidence of cognitive impairment, with elevated (n = 79) or subthreshold (n = 38) levels of cerebral amyloid were randomized, and 110 participants completed the study. Exercise was conducted with supervision and monitoring by trained exercise specialists. We conducted 18F-AV45 PET imaging of cerebral amyloid and anatomical MRI for whole brain and hippocampal volume at baseline and Week 52 follow-up to index brain health. Neuropsychological tests were conducted at baseline, Week 26, and Week 52 to assess executive function, verbal memory, and visuospatial cognitive domains. Cardiorespiratory fitness testing was performed at baseline and Week 52 to assess response to exercise. The aerobic exercise group significantly improved cardiorespiratory fitness (11% vs. 1% in the control group) but there were no differences in change measures of amyloid, brain volume, or cognitive performance compared to control. Conclusions Aerobic exercise was not associated with reduced amyloid accumulation in cognitively normal older adults with cerebral amyloid. In spite of strong systemic cardiorespiratory effects of the intervention, the observed lack of cognitive or brain structure benefits suggests brain benefits of exercise reported in other studies are likely to be related to non-amyloid effects